Print version ISSN 0104-0707
Texto contexto - enferm. vol.21 no.3 Florianópolis July/Sept. 2012
Jeferson RodriguesI; Silvia Maria Azevedo dos SantosII; Jonas Salomão SpricigoIII
IPh.D. in Nursing. Adjunct Professor, College of Nursing, Rio de Janeiro State University. E-mail: firstname.lastname@example.org
IIPh.D. in Education. Professor of the Department of Nursing and the Nursing Graduate Program, Federal University of Santa Catarina (UFSC). Email: email@example.com
IIIPh.D. in Nursing. Professor of the Department of Nursing, UFSC. Email: firstname.lastname@example.org
We investigated how mental health nursing care occurs through the discourse of faculty teaching psychiatric and/or mental health nursing contents in the four oldest nursing undergraduate courses in the State of Santa Catarina, Brazil, one of which is public, and the other three, private. Data collection was performed between March and May of 2010. This is a qualitative, descriptive and exploratory study. Data were collected in discussion groups, and analyzed according to the hermeneutic-dialectic perspective. The results showed that the faculty's discourses lacked the paradigm of psychosocial care and teaching based on psychopathology. In conclusion, teaching mental health nursing requires a theoretical framework based on paradigms consistent with the local situation and the Unified Health System.
Descriptors: Teaching. Care. Nursing. Mental health.
Teaching mental health nursing care, considering the dimension of comprehensive care, guided by the curricular reform, by the Psychiatric Reform, by the National Curricular Guidelines (DCN - Diretrizes Curriculares Nacionais)1 and guided by the paradigm of psychosocial care, faces the challenge of integrating the mental health field with the field of collective health. This fact required the Brazilian Nursing Graduate Courses to reformulate curricula and replan activities, focusing on new objectives based on contents that were closer and more integrated with the theory and practice of the professionals.
The utilization of the psychosocial paradigm appears as an opportunity to reconsider the education and training of generalist nurses under the principles of the Unified Health System (Sistema Único de Saúde - SUS) in Primary Healthcare. The mental health nursing care content specifically for the Nursing Undergraduate Course includes and integrates the health-disease-care process of the subject, family, and the community. That content must be consistent with the current epidemiologic and health situation so as to promote the comprehensiveness and interdisciplinarity of the interventions in nursing care and in health.
Nevertheless, teaching nursing under the light of the psychiatric reform and the psychosocial paradigm has occurred in a fragmented way, as they are still based on the care model focused on psychiatric institutions and on the therapeutic relationship as an intervention proposal. This underlines the dichotomy between theory and practice, as most programs of the mental health or psychiatric nursing disciplines of nursing undergraduate courses do not include the content of the psychiatric reform.2
It should be emphasize that there is a current concern by nursing schools in the state of Rio Grande do Sul, Brazil, in providing students with the chance to be in touch with new devices to provide care for individuals with mental disorders, supported on the principles of psychosocial care.3 In the state of Santa Catarina there is no information in this regard because there are no recent studies on psychiatric and mental health nursing, and, specifically, on nursing care in mental health and psychosocial care. One of the studies addressing teaching in this specialty, in Santa Catarina, performs an analysis considering the Brazilian situation in 1999.4
Teaching and care in mental health nursing, in general, require methods and systematizations based on the psychosocial paradigm, which include socially referenced physical and mental evaluations that connect with other knowledge and skills. Nurses should support their teamwork by participating in the creation and evaluation of the therapeutic projects of the subjects involved. Care, as a result of nursing practice in psychosocial care, involves the subjective and sociocultural inference of nurses, a permanent attitude of research and updating, increasing the space for participation and investing in the process of self-knowledge.5
Therefore, the epistemological and practical changes of care, influenced by the DCNs, psychiatric reform and SUS, require the nursing faculty working in mental health to reconfigure the education process be means of integrative contents that reduce the distance between what is taught and what is practiced. The teaching of mental health nursing care, as the object of this study, is justified by its possibility of providing an analysis, in terms of the curriculum changes, of the current historical and social moment that Nursing Undergraduate education is undergoing.
In this sense, we investigate how mental health nursing care is taught considering the national curriculum standards and through the discourse of psychiatric and/or mental health nursing faculty in the Nursing Undergraduate Courses in the state of Santa Catarina, Brazil, between 2009 and 2010.
This is a qualitative, exploratory and descriptive study. As it is impossible to work with the complete universe of faculty, we chose to work with the faculty teaching in the four oldest courses in the state of Santa Catarina. One of these courses is public, and the other three are private, and the faculty distribution is: one for one course, three for the other two courses, and two for the fourth course, totaling a universe of nine subjects. The choice for the faculty teaching in the oldest courses considered the history of the courses' curriculum reformulation, prior to the DCNs, and a possible comparison. It was also considered that the oldest courses have a critical analysis process and evaluations that are more consolidated and consistent with the curriculum changes over time.
Data collection was performed in group discussions,6 guided by instigating questions about the curriculum reform, the teaching of psychiatric and mental health nursing, with the curriculum change and the theoretical-practical teaching of nursing care in mental health. The groups were held at the institutions of the faculty, and were scheduled according to their availability. The researcher, in the beginning of the discussion group session, presented the faculty their projects, objectives and handed them two copies of the Free and Informed Consent Form to be signed. Four discussion groups were formed; one for each course. Each group session lasted between one and three hours. Data collection occurred between March and May 2010. The data from the Discussion Groups were transcribed and analyzed under the light of Psychosocial Care and Dialectic Hermeneutics,7 according to the proposed procedures: hermeneutic moment - legitimization of the data, interpretation and saturation; dialectic moment - emerging questions and dialectics; moment of the hermeneutic and dialectic synthesis - synthesis and surpassing. The ethical aspects were considered in terms of confidentiality and anonymity regarding the use of the information, in compliance with Resolution 196/96 of the National Health Council. This study was approved by the Ethics Committee for Human Research at Federal University of Santa Catarina, under document number 478, page 302344, in 2009.
RESULTS AND DISCUSSION
According to the faculty, teaching the theoretical activity of mental health nursing begins with the students' perspective regarding the mental health nursing discipline. Some discourses recognize the ethical-professional limitations involved in teaching care, when faculty understand each student's individuality, time, and personal motivations, which draw them towards or away from mental health care, within the teaching-learning process, evidenced in the following statement:
[...] we first worked with our student. On the first day of class we asked: what do you expect from this discipline? 'Professor, I'm afraid.' Afraid of what?, 'Afraid, afraid of getting beaten, afraid of mad people...' do you still see that today, after everything, what's the fear now? 'of not knowing what to talk to him about'. So we do a lot of work on the student because there is still a lot of prejudice (S5).
It is, thus, observed, that for some of the faculty, teaching mental health nursing begins by identifying the students' expectations regarding the discipline. One may ask: how can reason and sensitivity be used in theoretical teaching, when the objective is to prepare a critical thinking student, according to the profile recommended in the DCNs? How can theoretical teaching be developed, if technical training conflicts with existential training?
Self-knowledge, from the students' and the faculty's perspective, is a fundamental resource to prepare them with the skills to take care of others. In order to take care of the subject undergoing suffering one must take into consideration the aspects involved in the subject's existence, considering that the mental disorder condition involves the whole experience of the subject, from objective issues, such as work, housing, money, to how these issues imply on their subjective dimension.8
Teaching care, focusing on the student as an individual, comprises a careful attitude of careful listening, sharing experiences and not judging. Involving students in providing care to the client, being flexible, and offering the opportunity to ask questions and comment on their performance9 favors the teaching-learning process. On the other hand, the professor who teaches psychiatric and mental health nursing wants a student that is compromised with the patient, provides individualized care that is consistent with the current situation, and sees the patient as a person with biopsychosocial dimensions.10 These practices allow students to think critically about the care they provide, which involves their own emotional actions and reactions when caring, changing internally and externally, examining their personal and professional qualities, in order to develop interpersonal competence.
From the perspective of psychosocial care, the interpretation to begin the theoretical teaching of nursing care involves a sensitization with the student, consistent with the data, but with creative dynamics supported in group techniques, and with the objective to understand the ideation of the students and their perceptive change regarding mad and madness.
Regarding the theoretical contents, they differed somewhat among faculty and courses. In general, the approached contents were related to the psychiatric reform, the mental health policy, the person-to-person relationship, mental disorders, healthcare models and levels, and the organization of the mental health care network. According to the faculty of one of the courses, the way that the contents are selected depends on the political moment of mental health.
On the other hand, among the faculty of the four courses, the following strategies were used unanimously: reading and discussion of texts, showing and discussing movies. Some of the faculty reported they showed movies so they could use the situation of the characters to start discussions aimed at planning care. The faculty also used bibliographies to help in this process.
The faculty of one course, S2, S3 and S4, pointed at the utilization of case studies, texts about therapeutic listening and communication, in addition to others that address how to provide care to individuals undergoing suffering, implement services, mental care interventions in Primary Healthcare, problem-posing and planning in mental health.
There was silence among the faculty when they were asked about which criteria they used to choose the texts and movies, and why they chose these strategies over others. There was also silence among them regarding the use of active methodologies, considering that they are indicted by the DCNs for every course.
It is understood that when theoretical-methodological activities are performed in mental health education settings, there must be compatibility between the teaching methodology and the field of knowledge, which, itself, requires critical thinking, experimentations and evaluations. Teaching mental health nursing, in a critical perspective, requires a clear sight of the epistemological/conceptual dimension, a consistent educational aim, and choosing faculty trained in the new paradigm that involves mental and collective health.11
Therefore, in order for teaching and care practices in mental health nursing to become more thorough in terms of choosing the theoretical-methodological foundations, the psychiatric reform - permeated of paradigms in transition - is conjugated with the curricular reform, which is also inserted in the educational paradigms, which must be rethought by the faculty.
What marked the difference were the discourses used by the faculty that, because they were in a health care practice setting, used it to consolidate the theoretical teaching.
We have one program content that is developed, one part by the student who prepared the classes and delivers seminars, and the other through expository classes. Always with the students' participation, contributing with what they know, we use problem-posing (S5).
We work [theory] by describing the phenomenon of psychopathology and semiology of mental disorders in expository classes. We always work considering the DSM [Diagnostic and Statistical Manual of Mental Disorders] [in the practical part] as the professional that will work mainly in the outpatient clinic (S9).
Regarding the teaching of mental health nursing care, the faculty of three courses, S2, S5, S6 and S9, reported that the focus is on mental disorders and the alterations of mental functions, as well as the affected human needs, examined during the theoretical-practical activity.
We always stand up for the mental disorders issue here at the university (S2).
It does not concern only schizophrenia, bipolarity, it is about human beings who have a family behind them and problems behind them, who have children, all of this has to be taken into consideration (S5).
To me it is really important that they [students] are capable of telling what the symptoms and signs of schizophrenia are, what the conduct is, something somewhat systemized or else you get lost (S6).
We talk about the disorders reported by the Ministry of Health, by the World Health Organization, and, yet, by the DSM and APA [American Psychiatric Association] (S9).
An explicit contradiction emerges because while most faculty report the focus is on the teaching of care for mental disorders, some of the faculty of the same course also reports that the focus is not only on mental health care but also on the subject as a whole. Some courses emphasize that the care to subjects considering their complexity is more than taking care of the alterations caused by the disorders.
Although it is not the nurses' duty to make a diagnosis based on a medical conception, the biomedical model has still be pointed out as the main framework for reading the complex phenomenon that is a subject undergoing mental suffering. We did not identify any academic nursing production about the critical analyses of psychopathology teaching, but some nursing studies that criticize the technical rationale that originates from the biomedical model in the field of mental health and Psychosocial Care.12-13
It is observed that there are agreements and disagreements regarding theoretical education in mental health nursing care when care is involved. The development of care as a specific content was not reported, but appears as the understanding that it is intrinsically developed with the other content.
Professor S1, from another course, understands that mental health nursing care involves welcoming based on principles such as the perception and observation of individuals undergoing suffering, disposition, attention, listening, mutual interaction, evaluation of the condition of the person at that time, founded on the person-to-person relationship. However, in another course, professors S2, S3 and S4 understand that the teaching of care involves the perspective of listening and verbal communication, and that it takes place through health interventions. These professors report they face difficulties to access educational materials on health intervention and care. They indicate they turn to courses outside the institution for support, and they use the material from those courses as bibliographic reference to teach their students during the theoretical activities.
The content on health interventions is also developed through hypothetical situations, and prevention is related to risk groups, as observed in the following statements:
mental health nursing care we usually mention something when addressing the politics, what the nurses' role is in the politics. It is a very theoretical issue (S7).
during the 4th semester we also talk about systematization, but theoretically, for nursing care (S8).
for me I think it means to realize and observe the other, make yourself available to that other, pay attention, lend your ears [...] . So it means that, you are checking blood glucose and realize the person is suffering: 'I can talk for awhile, are you in a hurry?' (S1).
We start teaching the student a lot more about how they should listen [...] and that is actually the major tool: your ears and your mouth [...] (S3).
The discourses indicate that the teaching of mental health nursing care is based on the mental health policy, involved by the systematization of healthcare and nursing diagnoses, and that the nurses' practice is based on the symptom presented by the subjects, realized by the disposition, attention, listening and communication.
These data of the teaching of care also originate from the transformations of psychiatric and mental health nursing disciplines made considering a new dimension in the way of providing psychosocial care, which basic principle is not the remission of the psychopathological symptom, but understanding that symptom as something constructive of the subject with mental disorder. To do this, educational strategies are used, which permit to identify the mental process, the historically developed therapies, the public health policies, the complexity of the biological, psychological, social and anthropological fields, culminating in the materialization of the clinical practice in nursing, by means of interpersonal relationships, therapeutic communication, psychopathology, and psychopharmacology.14
The teaching of care based on psychosocial care conceives the person as unique and circumstantially ill, who speaks, feels, articulates thoughts, feelings and action, have a life history marked by objective and subjective aspects, in which falling ill and care have meanings.15 One aspect that must be taken into consideration is the time it takes for students to develop this care, as each one has their own pace to develop the teaching-learning process.
In relation to the definitions of mental health nursing care teaching, the faculty did not report any specific elaborations. There is a scarcity of productions that make a specific approach to the configuration of mental health nursing care in undergraduate education.16 In a general view, the majority of the literature in centered on definitions of general health care. However, the teaching of mental health nursing depends on the value that the faculty assigns to this content (theoretical-practical), from which they can produce this knowledge, and change/relate with the student, and the faculty praxis to choose in which theoretical-methodological circumstances that teaching will be planned and developed, discussed in the discourse of the faculty. Hence, the contradiction: although the psychosocial paradigm is not explicitly stated as a paradigm to support the teaching of nursing care, it would be in the critical and reflexive ideation that the faculty have for choosing to teach care based on determined paradigms. The DCNs1 offer the faculty the chance to revise nursing care within healthcare; however, it has been reported that the faculty prefers more traditional models, which means their practice cannot differ.
Overall, the discourses of the studied faculty indicated that teaching care faces theoretical difficulties when taught considering the perspective of the SUS, particularly regarding the prevention and promotion of mental health in the primary healthcare level, as observed below:
I work with this part and I think there really are gaps in the literature. Academically, what is promotion, prevention, what is treatment, what is rehabilitation? It is a simple class in which I only tech the concepts and the students make the plan because they have more difficulty in promotion and prevention; treatment and rehabilitation for is clearer for them (S2).
Teaching mental health nursing care depends on the concept of the mental health-mental disorder/mental suffering process. The conditioning and determinants of this process guide the actions on mental health prevention and promotion by reducing risk factors and increasing protection factors. Health planning guides the professionals and services in establishing their health/mental health interventions, through a unique therapeutic project for the subject and for the community. Care is based on health interventions aiming at comprehensive care, considering the complex life of the subject undergoing suffering: care is interprofessional, territorialized and intersectoral to replace the asylum model.
The debate on the promotion of mental health should involve the community, families, individuals and organized groups, considering that it is this particular health intervention that aims to change the determinants, which depend on the local culture and consist of an expression of the power relationships. This calls for a formulation of policies and social participation, as a collective responsibility.17
It appears that mental health nursing care finds in the SUS a challenge to be taught, because its complexity involves the appropriation over the comprehensiveness of health care, the management of care and services, social control and evaluations of the transformations resulting from this care for the subject undergoing suffering. Nevertheless, the teaching of nursing and mental health care must be supported on a theoretical framework, which should promote teaching-service, theory-practice integration.
Regarding the theoretical framework of mental heath nursing education, faculty from three courses, S1, S2 and S5 pointed out that the person-to-person relationship, proposed by Travelbee, and the Theory of Basic Human Necessities, of Wanda de Aguiar Horta, are the ones adopted. Other faculty, from another course, S7, S8 and S9, did not use any theoretical framework, as they did not have any specific theoretical-philosophical framework, and they also did not perform the therapeutic approach inherent to the theoretical-practical practice, but, rather, sought support on the national mental health policy by the Ministry of Health. The reported theoretical frameworks rise a question to whether or not they are being analyzed in a way that permits a relationship with the psychiatric reform, with the SUS, collective health, and psychosocial care, a concern that is absent in the discussion groups of the present study.
The theorist is Wanda, but we use the simplified process (S3).
Everything that is proposed by the Ministry, for psychiatric nursing, we also maintain Joyce Travelbee and they complete movement of the psychiatric reform of the Ministry of Health (S5).
But not one author, one specific theoretical framework, because, actually, we do not perform a therapeutic approach (S7).
It is necessary for theory to be consistent with practice, because the distance between them is, mainly, due to the equivocated understating of the theoretical-practical nature and its relationship with the type of theory that is most appropriate for understanding the social reality of nursing education and practice.18 Nonetheless, the movement that each faculty makes to become updated is intrinsic to the activity and was not identified in this study.
The theoretical bases specific for nursing education, as reported by the faculty of three courses, involve the person-to-person relationship and the Theory of Human Necessities, as well as systematization for the development of care. In order to think about the theoretical concept that is most adequate for nursing care, among all, it is necessary to think about the paradigms that exist in the teaching of mental health nursing.
Studies that addressed these paradigms report that there is a relationship between the variations that occur across them and the ideological changes of the social and political time of the society.19 Therefore, it may be emphasized that the paradigms that support mental health nursing education are: custodial medical paradigm, interpersonal relationships paradigm, holistic paradigm, psychosocial rehabilitation paradigm,19 and the paradigmatic transition to the field of psychosocial care.
Thus, the care concepts found in the discourses of the studies faculty point at the paradigm of interpersonal relationships as the central focus. On the other hand, the ideations of nursing care education do not point at the paradigm of Psychosocial Care.
In relation to the frameworks used for mental health nursing care education, it is observed there are no specific ones, as the faculty adopts psychiatric nursing books. The faculty from one course reported that the lack of specific literature on the theme compromises the teaching. It was noticed that when the faculty think about the specific care in the teaching of mental health nursing, the perspective of care as an epistemological object disappears. However, the way that each faculty selects the frameworks for teaching mental health nursing is specific to each course.
The practice of teaching mental health nursing care, as reported by the faculty, occurs through theoretical activities and by following students in the theoretical-practical activities.
The discourses of the teaching practice by the faculty, when considering the theoretical framework, show a paradigmatic transition, particularly of those whose interpretations point at practices that are not analyzed considering the psychosocial paradigm, explicitly. However, it is observed in the same discourses that there are acts and interpretations that are inserted in one model at one time, and in other models at others. It is understood that this paradigm serves as an analytical model of the psychiatric reform practices, to show if they are included in this or that model, considering the objects, means, institutional relationships, ethics, and purposes.
The highlighted contradictions are related to the object of the framework, because while it refers to the individual as a whole, there is a tendency to focus on the disorder. It is understood that this is inherent to each faculty, because of the autonomy they have to choose how to interpret and analyze their own practice in the field of mental health.
However, some faculty report that moving from theoretical to theoretical-practical activities occurs by first completing the former, which includes to follow the students in the service routine, when they (students) choose a subject to be followed. This period of practice ranges across the three courses, comprising three days in one course, twenty days in another, and an undefined hour load in another and also includes the student following the subject; in addition, there is a group discussion about their experience, whatever the diagnosis, what was done and the situations that occurred.
Regarding the developed methodological framework, the faculty (S2 and S5) from two courses reported they used the simplified nursing process. Some faculty reported that the practice of the students depends on the opportunity provided by the course faculty, the demand for mental health care, and the knowing-doing of the mental health faculty. According to other faculty, the teaching of care, both theoretical and practical, involves a network-based educational strategy from (and for) care. The practical teaching of care also involves problem-posing, person-to-person relationship and the student following the subject undergoing suffering.
The interpretations of the discourses regarding the practice show the importance of giving autonomy for students to develop the care, because they have their own pace. It was also highlighted how important it is for the faculty to follow the students, as their contact with the subject undergoing suffering can arise conflicts.
In some discourses, the use of the nursing process was adequate to the education of mental health nursing due to the location and the demand. Therefore, the process included topics about the background, the identification of problems, and the nursing care. For other faculty, students are affected by the form they see the faculty perform the care in mental health nursing.
Some interpretations showed that sometimes the students feel uncomfortable by the fact that they do not see nurses working in the service. It was observed it is important for the faculty to address this fact in the discussions, because interdisciplinarity20 implies the presence of the nurse in the team.
The interpretations imply that that the teaching of nursing care is based on the emotional, physical and social existence of the subject. For some faculty, this teaching also contemplates the study of psychiatric diagnoses and medications, it involves symptom relief and the improvement of quality of life.
In summary, the teaching-learning process of mental health care, as presented in the discourses of the faculty, depends on the interest, affinity and personal motivations of both faculty and students. This teaching of care begins by problem-posing the existence of the subjects undergoing suffering considering their complexity, and it requires a comprehensive clinical evaluation (physical and mental), an approach that aims at not reducing the subject. Care involves attachment, listening, communication, help in the process of elaborating conflicts, creativity, responsibility, group and team strategies, integration with the healthcare levels, with a priority set on primary healthcare. The teaching of care aims at social transformation, it includes an involvement with research and outreach, and a connection with the intersectoral network.
The materialization of teaching in mental health nursing care, perceived through the discourse of the faculty that teach the contents of psychiatric and/or mental health nursing in the oldest Nursing Undergraduate Courses in the State of Santa Catarina, reveals that this teaching does not occur as a specific content, but, rather, it is intrinsic and approached with other topics and contents, with emphasis on psychopathologies and the nurses' role in psychosocial care services. This result shows that the care with the integrative content for theory and practice is weakened, because it is being taught without the appropriate relevance, as this is the epistemic object of nursing.
However, mental health nursing care, today, in the SUS, faces a challenge to be taught, because its complexity involves the appropriation of the comprehensiveness of healthcare, the management of care, social control and the evaluations about the transformations that this care provides to subjects undergoing suffering. There is a need for a process in which the faculty seeks clarifications regarding the theoretical-methodological, scientific-political and ideological context in which care is taught. The clearness of this context also implies a teaching that is more focused on the emancipation of the student during the process of developing their knowledge in the generalist training. Nursing, as a discipline, and mental health, as a field of knowledge formed by nuclei that appear as something new and under construction.
This also means that nursing education, while aiming care at social transformations, will take place with faculty that is interested and seeks to investigate new paradigm constructs. This certainly requires efforts, because the possibility of nursing being emancipated by the study of care demands a historical review of the contradictions involved in the teaching of mental health nursing care and the respective advancements.
Planning the teaching of care based on the current situation of the demand in the territory requires a relationship to exist between the teaching-learning of the educational practice and a paradigm-based mental health nursing care model, evaluated and consistent with the local situation and the SUS. It is understood that mental health nursing care, from a generalist perspective, advances in a field of knowledge that is under construction, comprised by different knowledge centers regarding one broadened health/mental health concept, with multiple origins and resulting from the subjects' cultural, social and biopsychosocial life conditions. The psychosocial care strategy connects the principles and guidelines of the SUS with comprehensiveness, interdisciplinarity and health interventions and the polysemic field of mental health. In conclusion, the teaching of nursing care involves being prepared for its condition of contradiction that combines criticism to ideology in the field of mental health and faulty praxis with a view to social transformation and consistent with the SUS.
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Correspondence: Received: November 11, 2011
Rua Heber de Boscoli, 80, ap 201 - Vila Isabel
25501-110, Rio de Janeiro, RJ, Brasil
Approved: March 28, 2012
Received: November 11, 2011